MEDICAID DENTAL PROGRAM Policy Review Wyoming Medicaid is

MEDICAID DENTAL PROGRAM Policy Review

Wyoming Medicaid is a joint federal and state government program that pays for medical and dental care for low income and medically needy individuals and families. Wyoming Medicaid benefit expenditures generally receive 50 percent Federal match (FMAP). Medicaid provides medical assistance for lowincome and medically vulnerable citizens. There are currently four major categories of eligibility: Children, Pregnant Women, Family Care Adults, and Aged, Blind or Disabled (ABD). What is Medicaid?

The Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) or "Obama Care", is a United States federal statute signed into law by President Barack Obama on March 23, 2010. Under the law, a new “Patient’s Bill of Rights” gives the American people the stability and flexibility they need to make informed choices about their health. What is the Affordable Care Act (ACA)?

Expands income eligibility for children Transitions children from Kid Care CHIP to Medicaid Implements the Modified Adjusted Gross Income (MAGI) eligibility for children, pregnant women and family care adults Expands the availability of Medicaid benefits to former foster care children until age 26 How does the ACA impact Wyoming Medicaid?

Children’s program is mandatory by the federal government and covers all services needed to prevent and treat dental diseases and restore function. Adult program is optional and can be limited to basic services as determined by each state. Expansion of the adult coverage range is optional and must be passed by the legislature and governor for each state. Medicaid Dental

The Division of Healthcare Financing administers the Medicaid program. They are responsible for financial management, developing policy, establishing benefit limitations, payment methodologies, and fees, and performing utilization reviews. State Duties vs. Fiscal Agent Duties

The Fiscal Agent (Xerox Healthcare Solutions) processes all claims and adjustments. They also answer provider inquiries regarding claims status, payments, client eligibility, known third party payers and provide onsite visits to train and assist your office staff on Medicaid billing procedures or to resolve claims payment issues. State Duties vs. Fiscal Agent Duties

The Medicaid Dental Manager is responsible for presenting new policies, codes, and fees to the Medicaid Dental Advisory Group (DAG) for consideration. The DAG is made up of 6 dentists and Department of Health and Fiscal Agent employees. The DAG collectively reviews new or changes to existing policies for compliance with industry standards. Who reviews dental policies?

When would the DAG review a policy? 1. New ADA codes 2. Provider requested fee increase 3. Data shows outliers in billed charges 4. Clinical appeals from providers The DAG members also provide professional advice and expertise on current acceptable dental practices. What does the DAG do?

Dr. Dr. Jay Cole- Pediatric Dentist-Cheyenne Jim Nelson- General Dentist- Worland A. Bryce Castillon- General Dentist- Green River Thomas Zumo- General Dentist- Cheyenne Matthew Henry- Pediatric Dentist- Cheyenne Jim Hoag- State Orthodontic Consultant Members from the Wyoming Dental Association are invited to attend and participate at quarterly meetings as representatives of the professional association in Wyoming. Who are the current DAG members?

The Oral Health section of Public Health is not funded or managed by Medicaid. Public Oral Health has many programs that are paid for by State general funds to help assist uninsured or underinsured dental patients. These programs include: Senior Dental, Marginal Dental, Sealant Program, Cleft Palate Program, and part of the Severe Malocclusion Program. What is Public Health Dental?

Public Oral Health has a manager, Cassandra Walkama RDH, MPH and a dentist, Dr. Edward Lawler. These programs were previously administered by Trish O’Grady and Peggy Baluska. Public Oral Health also employees 4 Community Oral Health Coordinators (public health hygienists). Who is in charge of Public Oral Health?

In 2015, 231 of the 295 licensed, practicing dentists in Wyoming are enrolled as Medicaid providers WY ranks in the top 10 for provider participation and fee reimbursement in the nation. 78% of licensed dentists are MC providers. The national average is (40 -50%) How many dentists participate with WY Medicaid?

As of March 2015 there were: 46, 456 children on MC 27, 288 adults on MC 2, 106 nursing home residents on MC **Of the 46, 456 children on MC in 2015, only 21, 838 (47%) have been seen for a dental visit and only 18, 701 (33%) have had a prophy How many Medicaid clients are there?

Bill claims timely, within 12 months to avoid timely filing denials Retain adequate records Inform clients, in writing, if a service is not covered or if the client has used their benefit limits Report suspected abuse or fraud by another provider or eligible client (page 4 -5) Check client eligibility prior to rendering services Review and understand all policies contained in the provider manual What are my requirements as a provider?

Medicaid Program Integrity Unit is in place to do the following: 1. Review of claims submitted for payment 2. Review of dental records related to covered services 3. On-site review of dental records and client interviews 4. Case management oversight 5. Recovery of overpayments or payments made in error based on policies What is Program Integrity?

Each employee in the provider office are informed of Medicaid rules and policies Records are kept accurately on each client Access to client records as requested Access to financial records of reimbursement from Medicaid Office policies are enforced the same for all types of patients EX. Medicaid, Cash pay, Traditional insurance What is expected from Program Integrity?

A patient’s dental records must contain the following information and be typed or legibly hand written: *Name on each page of the record *Diagnosis of disease/conditions and history *Treatment Plan *All services rendered with: >Tooth Numbers >Surfaces >Quantities >Medications and dosages >Observed conditions & progress at each visit >Total treatment minutes if codes are used that are reimbursed at 15 minute increments What is required in the records?

The SMP is the orthodontic program for Medicaid Clients can be referred to an orthodontist if there malocclusion appear to meet the set guidelines Clients go through an approval process before ortho can be started Only clients who have poor malocclusions that affect function EX. Speaking, Chewing, Breathing, will be approved Severe Malocclusion Program